Chronic ketamine use resulting in a reversible cholangiopathy: A case series from a single Canadian centre and review of the literature

Background: Ketamine-related cholangiopathy is increasingly being described in America, Europe, and Asia, paralleling increases in ketamine use globally. However, ketamine-related cholangiopathy has not been described in Canada previously. We report three cases of ketamine-related cholangiopathy in Calgary, Alberta. Results: Between May 2024 and April 2025, three patients were assessed by the University of Calgary Liver Unit in Calgary, Alberta, Canada. Case 1 was a 28-year-old female referred for elevated liver enzymes and features concerning for sclerosing cholangitis identified on magnetic resonance cholangiopancreatography. Case 2 was a 40-year-old male referred due to features of sclerosing cholangitis identified on magnetic resonance cholangiopancreatography. Case 3 was a 33-year-old female referred for elevated liver enzymes with biliary dilation on abdominal CT scan. In all cases, a history of chronic ketamine use and a negative comprehensive workup for other etiologies strongly suggested ketamine as the cause of their presentations. Case 1 had normalization of liver enzymes and marked improvement of radiographic biliary changes at 3-month follow-up after complete cessation of ketamine. Case 2 reduced ketamine use by 50% and experienced similar clinical improvement at 3-month follow-up. Case 3 continued using ketamine, resulting in worsening liver enzyme elevations and persistent biliary tree imaging abnormalities. Conclusions: Chronic ketamine use should be considered in patients presenting with liver enzyme elevation and/or imaging evidence of biliary dilation. Increased awareness in Canada is essential to ensuring health care providers consider ketamine-related cholangiopathy in patients presenting with these clinical findings, as with ketamine cessation liver injury and biliary abnormalities are potentially reversible.